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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all Information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name(DBA): ND Kyq "O( C7!AVIJ p iC� <br /> Address for Vehicle: /civ oil• fe D LA Md Tlt7 *At=— <br /> street Address city <br /> 1) License Plate#: �32-78yj- 4) Year. <br /> 2) Vehicle Vin# M4fyJ6j.1-7"4t6 ! 5) Make/Model: <br /> 3) State Decal#: 6) Color. <br /> VEHICLE OWNER INFORMATION <br /> Name: #V07 )3Ftn <br /> Address of Owner. /80 u.1 frIM76 t.a) 44&CA7r 71Z)US1-- <br /> sheet Address City <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operating day for cleaning and servicing (CalCode sections 114295 & 114291). H the use of the commissary is <br /> discontinued, th perk der must notify this office to make the necessary changes. Failure to notify this <br /> office may resuls n pen vocation and penalties. <br /> Signature of Chicle qorator Date <br /> COMMISSA Y INF TION <br /> Business Name: /k)A) C 7—f U C CE <br /> Owner Name: LD <br /> Site Address: S, U fJ 6-F 5 D /C/ C4 $- 0 <br /> pstreet Address City <br /> Phone: ( �) , q _.Sq C <br /> 1,the Commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> dLiquid&solid waste disposal 93"Utensil washing sink ore frozen food [1iehicle wash facilities <br /> �,,/(2 dmfs) <br /> 1 't'r garation of food f Hot&cold water fox cleaning ,�/oilleet&hand washing M-gWra refrigerated food <br /> tore dry fo d/supplies rovide potable water (aO tight parking �dmequate electical outlets <br /> $ 27 /.S <br /> Si nature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> H the commissary/food establishment Is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissaryllood establishment Is In <br /> County. <br /> Signature of County REHS Date <br /> END 16-017 Sots WFPU APPLICATION <br /> VIM= <br />